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In the face of war: examining sexual vulnerabilities of Acholi adolescent girls living in displacement… Patel, Sheetal H; Muyinda, Herbert; Sewankambo, Nelson K; Oyat, Geoffrey; Atim, Stella; Spittal, Patricia M Dec 28, 2012

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RESEARCH ARTICLE Open AccessIn the face of war: examining sexualvulnerabilities of Acholi adolescent girls livingin displacement camps in conflict-affectedNorthern UgandaSheetal H Patel1,2, Herbert Muyinda3, Nelson K Sewankambo4, Geoffrey Oyat5, Stella Atim6 and Patricia M Spittal1,2*AbstractBackground: Adolescent girls are an overlooked group within conflict-affected populations and their sexual healthneeds are often neglected. Girls are disproportionately at risk of HIV and other STIs in times of conflict, however thelack of recognition of their unique sexual health needs has resulted in a dearth of distinctive HIV protection andprevention responses. Departing from the recognition of a paucity of literature on the distinct vulnerabilities of girlsin time of conflict, this study sought to deepen the knowledge base on this issue by qualitatively exploring thesexual vulnerabilities of adolescent girls surviving abduction and displacement in Northern Uganda.Methods: Over a ten-month period between 2004–2005, at the height of the Lord’s Resistance Army insurgency inNorthern Uganda, 116 in-depth interviews and 16 focus group discussions were held with adolescent girls andadult women living in three displacement camps in Gulu district, Northern Uganda. The data was transcribed andkey themes and common issues were identified. Once all data was coded the ethnographic software programmeATLAS was used to compare and contrast themes and categories generated in the in-depth interviews and focusgroup discussions.Results: Our results demonstrated the erosion of traditional Acholi mentoring and belief systems that hadpreviously served to protect adolescent girls’ sexuality. This disintegration combined with: the collapse oflivelihoods; being left in camps unsupervised and idle during the day; commuting within camp perimeters at nightaway from the family hut to sleep in more central locations due to privacy and insecurity issues, and; inadequateaccess to appropriate sexual health information and services, all contribute to adolescent girls’ heightened sexualvulnerability and subsequent enhanced risk for HIV/AIDS in times of conflict.Conclusions: Conflict prevention planners, resettlement programme developers, and policy-makers need torecognize adolescent girls affected by armed conflict as having distinctive needs, which require distinctiveresponses. More adaptive and sustainable gender-sensitive reproductive health strategies and HIV preventioninitiatives for displaced adolescent girls in conflict settings must be developed.Keywords: Adolescent girls, Conflict, Sexual vulnerability, Displacement camps, Northern Uganda, Acholi,Qualitative, HIV/AIDS* Correspondence: spittal@sm.hivnet.ubc.ca1Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada2School of Population and Public Health, University of British Columbia,Vancouver, BC, CanadaFull list of author information is available at the end of the article© 2012 Patel et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Patel et al. BMC International Health and Human Rights 2012, 12:38http://www.biomedcentral.com/1472-698X/12/38BackgroundThe intersection between war, displacement and HIV/AIDS is particularly striking in Northern Uganda. Theover two-decade war between the Government of Uganda(GoU) and Joseph Kony and his rebel force, the Lord’s Re-sistance Army (LRA), has been characterized by the killingand maiming of civilians, child abductions, widespreaddisplacement, various forms of sexual and gender-basedviolence, and the destruction of the social and economicfabric of society [1-3]. These experiences have left the en-tire population traumatized and at a heightened risk ofcontracting HIV/AIDS.Northern Uganda, or Acholiland as it is often referredto, is comprised of three districts, Gulu, Kitgum, andPader and spans an area of 28,000 square kilometres,equivalent to the size of Rwanda. Over a million and ahalf people reside between the three districts, of which99% are of Acholi ethnicity and 1% other tribes. Acholi-land is a vast and sparsely populated area with consider-able agriculture and livestock development potential. TheAcholi are traditionally a people of agriculturalists andlivestock breeders and prior to the conflict, ninety percentof people in the northern region lived in rural areas.In 1986, after President Museveni took power in Uganda,the rebel factions that have mobilized to resist this govern-ment can be characterized by transitions of increased ter-ror, with Joseph Kony being the craft perpetrator of someof the greatest human rights violations the world has everseen. Even though Joseph Kony and his rebel force, theLRA, professed to fight a spiritual war for the Acholipeople against the GoU and its military, the Ugandan Peo-ple’s Defence Forces (UPDF), the majority of Acholi peopledid not respect or voluntarily assist the LRA. This repudi-ation can largely be attributed to the enhanced phase ofterror inflicted upon the civilian population after the peacetalks brokered by Betty Bigombe in 1994 fell apart. Rape,landmines and the mass abduction of children as comba-tants became the signature work of the LRA. To this day,the facial mutilations of women who had their lips, earsand noses severed at gunpoint are visible in displacementcamp settings.When the peace talks failed, the Sudanese governmentallegedly began to heavily support Joseph Kony [4]. Byproviding safe refuge in the form of encampments, landto cultivate, materials to build homesteads, hospitals fortreatment of war-related injury and even pharmaceuti-cals for treatment of common infections such as sexuallytransmitted infections (STIs), the Sudanese supportedthe LRA by enabling them to systemize their incursionsinto Uganda from protected base camps in the Sudan.To a large extent the Sudanese support of the LRA, in-cluding weapons, ammunition and landmines, was thekey factor in consolidating Joseph Kony’s reign of terroras the longest child hostage crisis in human history [4].By October of 1996 the casualty levels were high, thenumbers of abducted children numbered close to fivethousand and, the conflict had intensified with rebelincursions becoming a normal part of daily life. Due tothe focused efforts of the LRA the GoU facilitated theshift of villagers into Internally Displaced Peoples (IDP)camps, and approximately 210,000 villagers moved fromtheir homes into government-sanctioned camps [4]. Vo-luntary movement was not considered an option. At thetime, most of the camps were located in the Kilak, Aswaand Nwoya counties of Gulu district, as they were themost affected by rebel incursion. By the year 2000, therewere approximately 23 government-recognized camps inthe region [4].In the wake of September 11th, 2001, and with increasedpressure by the US government on Islamic states support-ing terrorism, the Sudanese and Ugandan governmentscommitted to improving bilateral relations. In March2002, the Ugandan government launched ‘Operation IronFist’ (OIF), a military offensive against the LRA. Thou-sands of ground troops and air support were deployed.The government’s intention was to resolve the situation inthe North using military force, and diminish the effects ofwhat was becoming an international embarrassment forthe government. In response, the LRA rebels poured backacross the Ugandan border and sought revenge againstthe civilian population with intensified attacks on commu-nities, increasing abductions and forced recruitment. Thenumber of abducted children under 18 years of agejumped from approximately 12,000 as of June 2002, tonearly double that by June 2003 and at least 30,000 byMay 2004 [5].As LRA attacks and abductions increased, and districtsin Northern Uganda previously relatively unaffected bythe war became targets of the LRA’s insurgency, unpre-cedented numbers of people fled their homes and weredisplaced into IDP camps all over Acholiland. The totalnumber of people displaced and aid-dependent swelled.While in August 2001 there were an estimated 480,000IDPs, by 2005 the total number of displaced persons hadexpanded to over 1.8 million, which accounted for over90 percent of the population of Northern Uganda [6-8].At that time, nearly 70 percent of the displaced popula-tion was under 25 years of age [9]. With the majority ofpeople in the northern region now in camps, an unin-tended consequence of OIF was the complete destructionof Northern Uganda’s economic base, agriculture. Likemany conflict-affected regions across Africa, Acholiland -once a very fertile region of the country - was leftneglected, untended and uncultivated.Women/girls, HIV vulnerability, and conflictIn times of conflict, adolescent girls are caught in a webof vulnerability created by the social disarray of war.Patel et al. BMC International Health and Human Rights 2012, 12:38 Page 2 of 12http://www.biomedcentral.com/1472-698X/12/38Indeed, the power imbalances that heighten girls’ sexualvulnerability and enhance their disproportionate risk forHIV/AIDS become even more pronounced during con-flict and displacement [6,10]. Contributing factors whichincrease the spread of HIV in the context of conflict in-clude: breakdown of family and other social and commu-nity structures; increased dependence on men for physicalor economic security; lack of access to sexual health infor-mation, health care and social services; increased sexualand gender-based violence, and; sexual interaction betweencivilians and combatants [6,11,12]. All of these factors rep-resent critical challenges for the international communitywith regard to programme response in times of conflictand, more often than not, resources available fall short ofthe scope and complexity of the challenges [13].Even though Uganda has won international recogni-tion for its progress in HIV research and prevention,regional disparities persist. According to the UgandanSero-Behavioural Survey last conducted in 2004/05, HIVprevalence among young people aged 15–29 was esti-mated at 9 percent among females and 7.1 percent amongmales for the whole North Central Region, while the na-tional average figures were 8 percent and 5 percent re-spectively [14]. Overall prevalence in Northern Ugandawas 8.2%, the highest in the country. However, these esti-mates are limited, because HIV prevalence rates arereported regionally and this makes it difficult to ascertainand compare rates in the districts most impacted by con-flict, and therefore limits opportunity for further analysisby sub-group.Although it is recognized that the relationship betweenconflict and HIV transmission is highly complex andcontextualized and, that the ultimate effects of conflict(i.e. augmenting or reducing HIV risk) are continuouslydebated, [6,8,11,15-17] it has been well established thatin conflict settings adolescent girls experience heigh-tened sexual vulnerability and increased exposure oppor-tunity to HIV [1,11,17-19]. Mock et al. (2004) state thatvulnerability factors (i.e. poverty, malnutrition, lack ofhealth services), and exposure opportunity factors (i.e.increased sexual violence and physical violence) are thebasic determinants of population-level HIV risk andthat, seen in this way, conflict should be viewed as a keydeterminant of HIV vulnerability [11].A study conducted by the Women’s Commission forRefugee Women and Children demonstrated that amongchildren living in IDP camps, the idea of a ‘safe passage’from childhood to adolescence to adulthood no longerexisted and that this is particularly the case for adoles-cent mothers [20]. Furthermore, research suggests thateven though adolescent girls are gradually receivingmore attention from programme developers and policy-makers, the child protection community, academia andother stakeholders must strive to deepen the knowledgebase on adolescent girls’ distinctive vulnerabilities to HIV/AIDS during times of war in order to inform more effect-ive advocacy and programme interventions [3,11,13]. Themain objective of this study was to provide a betterunderstanding of adolescent girls’ enhanced risk forHIV infection in conflict settings by examining the sexualvulnerabilities of Acholi adolescent girls living in displace-ment camps in Northern Uganda, to inform the develop-ment of appropriate sexual education and HIV preventioninitiatives in this population group.MethodsStudy design and sampling strategyTo understand the distinct vulnerabilities of conflict-affected Acholi adolescent girls and to in-turn developculturally sensitive HIV/AIDS programming, the perspec-tive of risk and HIV vulnerability of adolescent girls, be-fore and during conflict, must be thoroughly understoodin the context of Acholi culture. As such, a qualitative ap-proach including interviews with a broad sample of girlsand women who were resident in one of three IDPcamps in Gulu district (Pabbo, Palenga or, Awer) wasdeemed necessary to fulfill our research objective. BetweenNovember 2004-September 2005, participants wererecruited using convenience sampling, on the basis ofproximity, age and consent. This sampling strategy enabledresearchers to select informants who were easily accessible,either by nature of their geographic proximity or theirconnection to other research participants. The studyteam collaborated with hired community members ineach site, who assisted with the recruitment processby mobilizing prospective age-eligible participants.Sample sizeOver a ten-month period, 116 in-depth interviews and16 focus group discussions (including 6–10 participantseach) were held in the three camps with adolescent girlsand adult women. Disaggregated, these consisted of 59in-depth interviews and 8 focus group discussions withadolescent girls aged 14–19 years and, 57 in-depth inter-views and 8 focus group discussions with adult womenover the age of 30 years. A breakdown of the sample byIDP camp is presented in Table 1.Data collectionInformed consentAll research participants provided written or thumbprintinformed consent. The permission of the head of house-hold was obtained before any members of the familyparticipated in the study. In addition, every adolescentunder the age of 18 must have had the consent of theirparents/guardian before they could participant in thestudy. A number of adolescent girls qualified as matureminors (i.e. girls under the age of 18 who were married,Patel et al. BMC International Health and Human Rights 2012, 12:38 Page 3 of 12http://www.biomedcentral.com/1472-698X/12/38currently pregnant, or already having children) and,therefore, were permitted to give their own consent. Theconsent forms were discussed in the local language ofLuo to ensure consistency and clarity in the consentprocess. Only after full understanding of study proce-dures had been established, written or thumbprintinformed consent was obtained for participation in thestudy. It was made clear to all involved that they couldrefuse to answer any question and that their withdrawalfrom the research at any point would warrant no nega-tive consequences.Interviews and focus group discussionsHighly trained, female, Acholi interviewers, bilingual inthe local language of Luo and English, conducted the in-depth interviews and facilitated the focus group discus-sions. The interviews and group discussions exploredissues including: camp/bush living; knowledge and per-ception of risk for HIV and other STIs; traditional waysof communicating/learning about sex and sexuality, and;perception of current availability and/or barriers to sex-related information and HIV care services. The in-depthone-on-one interviews took a narrative approach, usinga series of prompts to allow participants to relate theirunderstandings and perceptions of risk for HIV/AIDS,their knowledge of traditional ways of learning aboutsexuality and, the availability and barriers to sex-relatedinformation in the context of war and displacementcamp living. New concerns, vague answers and contra-dictory ideas from the in-depth interviews were formu-lated into discussion topics and became part of the topiclist used to guide the focus group discussions. The groupdiscussions provided an opportunity for participants tocompare their stories with others and, through inter-action, articulate particular meanings of HIV-related vul-nerabilities and the impact of the on-going conflict forthemselves. Group interviews proved useful, as manyexperiences and perceptions were only identified whenparticipants could compare them with the experiencesand perceptions of other participants.To ensure confidentiality of the data collected, all par-ticipants were identified by unique, pre-printed numericstudy ID numbers (no names or personal identifiers werecollected). In addition, all interviews and focus groups wereconducted in total privacy by highly trained, same-sexinterviewers, and no information was disclosed to respon-dents’ family members. All interviews took place at theparticipant’s home in a private and quiet place of theirchoosing and focus groups discussions were conducted inspare meeting rooms at local organization’s offices, incomplete confidentiality. As discussion of sensitive issuesand traumatic experiences could precipitate feelings of dis-tress, every study participant was offered immediate refer-rals for psychosocial support as well as general healthcare;all referrals were made at the participant’s request.Ethical considerationsEthical approval was obtained from the Institutional Re-view Boards from the University of British Columbia,Vancouver, Canada and Makerere University, Kampala,Uganda.Data analysisWith participants’ permission, all interviews and groupdiscussions were audiotaped and subsequently transcribedby the Acholi research team in Uganda. A thematic ana-lysis of the data was conducted using procedures for quali-tatively derived data [21-23]. The main aim of the analysiswas to identify issues that commonly emerge in the inter-views and focus groups, which help to explain the sexualvulnerability of displaced adolescent girls. After the datacollection process was complete in two of three of the IDPcamps (Pabbo and Palenga), members of the researchteam familiarized themselves with the data by repeatedlyreading interview and group discussion transcripts whileat the same time making notes on identified patterns inthe data. The notes were then collated and sorted into ca-tegories and sub-categories representing themes/recurringissues that were common across many different interviewsand group discussions. Dynamic dialogue and reflectionwith our Acholi colleagues regarding the emerging the-matic trends informed the development of our analyticframework. An initial coding scheme was developed thatthe team together agreed was a fair representation of theemerging thematic trends in vulnerability reflected in thenarratives and stories of the adolescent girls and womenwe interviewed from Pabbo and Palenga IDP camps. Sub-sequent interviews conducted in Awer camp were used toconfirm or refute the themes/trends in vulnerability thathad previously been identified in the other two camps. Asmore data were collected and analyzed, coding categorieswere refined. Credibility of the thematic analysis was con-tinually evaluated with the members of our research team,leaders and experts in HIV/AIDS and, community mem-bers. Community feedbacks were essential in developing adeeper understanding of patterns of risk and vulnerabilityand finding agreement among camp membership relatedto the main themes identified in the narratives andTable 1 Breakdown of sample based on IDP campPabbo Palenga Awer TotalIndepths (n = 116)Adolescent girls 30 15 14 59Adult women 27 14 16 57Focus Groups (n = 16)Adolescent girls 3 3 2 8Adult women 3 3 2 8Patel et al. BMC International Health and Human Rights 2012, 12:38 Page 4 of 12http://www.biomedcentral.com/1472-698X/12/38experiences of participants. All decisions related to ana-lysis were carefully recorded. Once all the data had beencollected and coded, we used the ethnographic computersoftware package, ATLAS, to organize, compare andcontrast key themes and categories generated in the in-depth interviews and focus group discussions. Excerptsfrom the narrative data presented in this manuscript areannotated with type of interviewee [adolescent girl(s) oradult woman/women], prefixed by (I) for one-on-oneinterviews or (G) for group discussions.ResultsThree broad thematic areas emerged that described thesexual vulnerabilities of displaced adolescent girls: 1)Understanding the Devastation of the Present: Erosion ofCultural Processes and Belief Systems and the Collapse ofLivelihood; 2) Living in ‘Double Jeopardy’: Vulnerability inthe Light of Day and Vulnerability at Night, and; 3) Accessto Reproductive and Sexual Health Information.THEME I: Understanding the devastation of the present:erosion of cultural processes and belief systems and thecollapse of livelihoodThrough early discussions with our Acholi research teamand the analysis of the data, it became clear that tradition-ally and in the not too distant past, Acholi girls expe-rienced significantly high levels of personal and sexualsecurity prior to marriage. The structured mentoring rolesplayed by female relatives combined with belief systemsthat mitigated against premenstrual sex and emphasizedthe culturally imbued concept of personal and communityconsent, represented a child protection system that placeda high value on the Acholi girl’s personal and familial dig-nity and served to protect her sexuality.The role of the grandmother (‘adaa’) and aunt (‘wayo’)In-depth interviews confirmed findings from existing li-terature on traditional Acholi mentoring systems. Speci-fically, grandmothers and the huts in which they residedwere pivotal in the transmission of sexual health know-ledge and mentoring of young girls. While girls wereindeed raised by their mothers and fathers, the grand-mother (‘adaa’) played a significant role in the upbring-ing of female children in offering mentoring andguidance via story telling in the privacy of her own hut[24,25]. The grandmothers generally taught the girlsabout men, the importance of not moving in with menbefore they menstruated, marriage, the clan system andincest taboos. As one girl who went through the mento-ring process describes:“We girls had a separate sleeping hut. Mygrandmother would come to our sleeping hut in thenight. She told us how to behave and be respectful toother people. She used to tell us that a responsible girldoes not answer back when she is talked to, and whenshe is being addressed, she sits down. If she is calledshe comes and kneels down, and listens to whatshe is told. . .that is what a bright girl does.” [(I)Adolescent Girl]Similar to other Ugandan cultures, among the Acholi,intergenerational taboos exist regarding discussing sex.Mothers did not speak to their daughter’s about sex, andthis role became associated with the ‘wayo’. The ‘wayo’,the father’s sister, was responsible for socialization ofyoung girls into (proper) womanhood and assumed asister-like role in the girl’s life. She taught her niecesabout various aspects of maturing in Acholi culture,relayed sexual health information, and was expected tobe a trusted secret keeper, a mentor, and confidant. Asone woman describes:“A wayo is a mentor, secret keeper at the onset ofmenstruation. . .to teach you everything . . . even howto have sex with your husband, because you may havegrown up with ignorance. She may teach you that ifyou have a man and he has called you to go to hishome . . . when you are to have sex you are to do thisand that, otherwise you may not be enticing enoughfor him.” [(I) Adult Woman]Premenstrual sex and the idea of consensual sex in AcholicultureTraditionally the age of sexual debut for Acholi girlswas between the ages of 16 and 18 years and could onlyoccur after the female child had had a number of regu-lar menstrual cycles [24]. According to interviews withadult women, prior to the war premenstrual sex was for-bidden and was the cause of much consternation andstigma for both families involved. In fact, if a child wasdiscovered having sex prior to menstruation the inci-dent became a kin and community issue and was dealtwith in the same manner as a sexual assault that tookplace in the bush. Rituals would have to be involved thatincluded compensation from the man’s family. As onewoman explains:“An appeasement ritual is performed at the spotwhere the rape took place. This would involve a goat(provided by the boys family) being slaughtered at theexact spot of the rape.” [(I) Adult Woman]This ritual was justified, as it was believed that pre-menstrual sex was the cause of future problems with fer-tility for the girl who had been violated. Seen in thisway, a female child’s sexual debut was culturally sanc-tioned and became a family/kinship issue.Patel et al. BMC International Health and Human Rights 2012, 12:38 Page 5 of 12http://www.biomedcentral.com/1472-698X/12/38When a girl had menstruated, she could begin receiv-ing suitors. The men would first arrive at the family com-pound where aunties, mothers and grandmothers woulddetermine a relationship’s potential by eliminating thepossibility that the couple could be in some way related.After it was determined that a union was possible, court-ing could commence and eventually the suitor obtainedpermission to propose. However, prior to bride wealthnegotiations a girl had to actually provide her consent tothe relationship and to sexual relations. One woman dif-ferentiated between traditional Acholi customs related tocourting and the current state of affairs in the camps:“If a boy began to court you he had to first presenthimself at your home and your mother would have tosee him . . . when you consented to a boy’s proposal itwas done by giving him such articles like beads,handkerchiefs, bangles . . . but the girls of today theyconsent with their bodies . . . by the time you get toknow your son’s fiancée he will have had relationshipswith many girls . . . In the past a boy couldn’t justcome and use a girl.” [(G) Adult Women]Parents expressed grief that adolescents would nowrarely comply with them, and that they no longerobserved traditional moral values including: respectingelders; protecting their virginity; abstaining from pre-marital sex and pregnancies, and; recognizing the import-ance of marriage. Adding to the change in behaviouralnorms was the powerlessness that girls and women inour study described as being associated with the con-gestion of IDP camp living. Displacement camp livingrepresented to both girls and women a shift in their sexualdecision-making from control and consent to passivity andacquiescence.Collapse of livelihoodOperation Iron Fist, the military offensive against theLRA launched by the Uganda government in 2002, crea-ted circumstances where more people were displacedfrom traditional homesteads and interrupted significantlythe households ability to generate income from the sale ofharvests including groundnuts, sim-sim and maize. Whenfamilies cannot dig and become completely food-aid de-pendant, the most vulnerable of all are the daughters. Themajority of participants (76% of individual interviews)lamented the lack of meaningful agricultural productionsince the commencement of displacement camp livingand commented that with the exception of performingcasual labour for people who had access to their land,there were very few employment opportunities especiallyfor girls and women, in or outside the camps. This lack ofdynamism in IDP camp economies has kept displacedfamilies in perpetual poverty and has led to fundamentalchanges in the way women and men lead their lives andprovide for their families. As one participant suggests:“Life is hard because there is hardly any means toearn income. It is because we do not have access toland due to insecurity. The land we dig, we rent orborrow but it is so little. Since there is no usefulcultivation, we cannot afford to pay fees for ourchildren, feed them and look after ourselves.” [(G)Adult Women]Mothers reported that this inability to provide for theirfamilies left women and girls powerless and economic-ally dependent on men, particularly adolescent girls.“Every time you go to get water, a girl will washherself and go to chat or stand by peoples kiosks . . .eventually the owner or trader in the kiosk will beginto seduce her. He will first buy for her pens, soap,books and other small presents . . . he will eventuallyask for sex . . . he will say I have helped you a lot soyou should also help me . . .they have to give himwhat he desires.” [(G) Adult Women]Furthermore, the inability of families to meet the sub-sistence needs of their daughters was directly related tothe decision of many girls to participate in ‘survival sex’,even exchanging sex for menstrual pads and biscuits.One 13-year old girl describes her experience:“The only alternative is for you to go to a boy/man, sothat he can help you with money to cater for thingslike clothing, food and other necessities. If you spenda night with the army officer at the barracks, the nextday you will change to another man, provided hegives you some money.” [(I) Adolescent Girl]The pain and indignity that mothers felt of being sopowerless in the face of such predation was clear. Mostcamp residents survived on food that was supplied bythe World Food Programme (WFP), and women also re-lied on these rations to earn some income. Mothers com-mented that they would either sell portions of their foodrations to buy the things that their daughters felt theyneeded, or give rations to their daughters to sell them-selves to try and prevent sex-for-exchange relationships.“We sell part of it to buy soap, clothes and othernecessities. . .now we are being taught that no matterhow much food ration you get, you must give a littleto the girls so at least she can get some money to buyherself a petticoat (skirt slip) or a panty . . . girlsmust come to us for the things they need.” [(G)Adult Women]Patel et al. BMC International Health and Human Rights 2012, 12:38 Page 6 of 12http://www.biomedcentral.com/1472-698X/12/38THEME II: Living in double jeopardy: vulnerability in thelight of Day and vulnerability at nightVulnerability in the light of dayBefore the on-set of war an Acholi girl who was not inschool would accompany her mother to the garden,weed and clean the garden, be involved in the harvestand storage of foodstuffs, collect firewood, and haulwater. This served as part of the socialization processand offered protection, as a child would be under theguidance and control of an adult. Since the war however,as many families were so afraid of abduction of theiryoung ones, particularly girls around the ages of 10, 11and 12 years, they started leaving their daughters behindwithin the relative protection of the camps.“In the past while we were in our homesteads a boyor girl could have her own garden. . .but now becauseof the camp and insecurity, which limits movement tothe gardens, the girls have become lazy.” [(G) AdultWomen]“Ever since the government ordered everybody intothe camp, due to the escalation of rebel activity, Ihaven’t allowed my children to move far away fromthe camp. It’s I who volunteers and exposes myself tocarry firewood, cassava and anything with which tofeed them, so they could remain in the camp. Theyshouldn’t go anywhere; they should remain in thecamps to avoid abduction.” [(I) Adult Woman]It was commonly reported (64% of individual inter-views with adult women) that in the absence of adultsupervision girls who were left behind in the camps du-ring the day were vulnerable to potential harms, includ-ing sexual predation. As one woman observes:“Supposing you leave for the garden, she will alsoleave for an unknown destination. You return fromthe garden only to hear rumours about her badconduct all over the camp. In our absence she willhave gone to have sex with a boy in the daytime. Inmy case, my daughter is spending time with boys intheir huts.” [(G) Adult Women]This situation whereby mothers were forced to leavegirls idle and unsupervised in the camps during the daydue to security concerns was quite different from leavingyour daughter at home alone in a village-setting, prior tothe war, where homes were at least three kilometresapart. For a child to move from household to householdlooking for where to sleep and to get something to eatwas totally unacceptable in the Acholi culture. It wasdisgusting, worrying, and it undermined the socializationprocess. Parents reported feeling incompetent and uselessin such circumstances and felt that their power and rightsto protect their families and children had been taken awaywith the on-set of displacement camp living.Contributing to this vulnerable situation was largenumbers of adolescent girls dropping out of school and/or diminished school attendance. A common situationdescribed in focus group discussions with mothers inthe camps was adolescent girls leaving school due to earlypregnancy and early marriage or because they could notafford the uniform and other costs associated with school-ing (i.e. books, pencils), despite the fact that primaryschool is free in Uganda. Furthermore, some childrenmissed classes because they were afraid of being abductedon the way to and from school while others failed to at-tend to avoid the stigma associated with going to schoolwith their younger peers. There were no adult educationprogrammes or accelerated learning programmes pro-vided in the camps to help children catch-up in schooltherefore many children who lost school time during thewar (including children who were abducted) were forcedto (re) join with classmates who were much younger thanthem. Due to their older age, children felt out of place inschool and many of them subsequently dropped-out.Many parents (60% of individual interviews with adultwomen) indicated that girls being out of school coupledwith the fact that children were no longer accompanyingand assisting their mothers in the garden, increased girls’vulnerability to predation during the day.Vulnerability at nightThe night-commuting phenomenon during the war, wherethousands of children flocked from their villages to Gulutown to sleep in churches, hospitals, and on verandas inorder to avoid abduction and other violence, is well docu-mented [26]. At its peak in the spring of 2004, there were40,000 children commuting every night. Children wouldwalk several kilometres to town every night to sleep; inthe morning they would walk back home, go to school,and then come back into town to sleep again. VariousNon-Government Organizations (NGOs) responded tothe crisis by organizing sleeping shelters in urban centres.At that time, NGO reports highlighted concerns about thepredation and sexual abuse/violence of girls as they movedunescorted from villages to the sleeping centres [26].Through our interviews, we uncovered another concern-ing ‘night-commuting’ trend that was characteristic of theIDP camp situation and was of great concern. Girls andboys were moving away from their families’ huts at duskto sleep in other huts within camp perimeters. For themost part, many children were moving to circumstanceswhere an older cousin was the only person providingsupervision to a hut full of children, both girls and boys.The explanation for this ‘internal’ night-commuting bychildren in IDP camps is two-fold. First, when childrenPatel et al. BMC International Health and Human Rights 2012, 12:38 Page 7 of 12http://www.biomedcentral.com/1472-698X/12/38were old enough to understand their parents’ need forsexual privacy they traditionally did not sleep in their pa-rents’ hut but rather in their grandmothers’ hut or thebachelors’ hut [24]. It appears that children were still fol-lowing these cultural traditions in IDP camp settings. Sec-ond, if families were living on the periphery of the camp,their children were at increased risk for abduction by thevery nature of the location of their hut. For security rea-sons, parents would attempt to negotiate a safe hut fortheir child to sleep in closer to the center of the camp.Some families, early in camp settlement, may have securedenough land to build two huts for their own families. Fre-quently, these huts would come up for ‘rent’ to thosefamilies who needed alternative arrangements for theirchildren. According to both the women and girls we inter-viewed it was during this ‘internal’ night-commuting whengirls were most vulnerable to predation by men whowould be offering food and clothing in exchange for sex;many girls we interviewed (52% of individual interviewswith adolescent girls) reported that this is when their sex-ual debut occurred. The following quotes illustrate thisconcerning trend:“If you are old, you cannot share room with yourparents; you will go and sleep with your relatives, soyou are showing them respect.” [(I) Adolescent Girl]“Their lives are spoilt. At night they roam about thecamps, going out to visit their boy friends, where theyspend the night and come back in the morning. Thisis because they don’t sleep in the same house withtheir parents. So the parents don’t know what thegirls do at night.” [(I) Adult Woman]THEME III: Access to reproductive and sexual healthinformation/servicesVarious sources of sex/HIV/AIDS information in theIDP camps were identified by discussants. Participantsreported receiving information from: parents; elder sis-ters and brothers; teachers; (sex) magazines; StraightTalk (a monthly article in the New Vision newspaper);radio programmes; health workers; sexual partners; peers;church, and; pornographic video shows. However, a com-mon finding was that many of these information sourceswere not necessarily cognizant of the current realties ofadolescent girls living in displacement camps, which in-turn diminished their overall benefit. As one girl explains:“When they [family planning services] are teachingabout condoms, they usually restrict it to people of18 years and above. They are the ones who are advisedto use it. The use of family planning is for marriedwomen (those with husbands) not for girls. . .younggirls in the ages of 12–14 years don’t have anyknowledge about condoms.” [(G) Adolescent Girl]Similarly, FM radios were reported to be sources ofsex/HIV/AIDS information; they communicated infor-mation on how to use condoms, avoid STIs/HIV/AIDSand unwanted pregnancies, and encouraged blood testingfor HIV. However, some adolescents noted the shortcom-ings of these campaigns including redundant repetitionand incongruity between the assumptions of the broadcas-ters and the children’s realities. For instance, radio presen-ters took for granted that condoms and medical serviceswere readily available in camps, which was rarely the case.In fact, an over-whelming majority of adolescent girls (91%of individual interviews) found it difficult to obtain con-doms in the camps. Furthermore, most adolescents lived inhomes that could not afford to buy radio batteries, leavingmany children without access to the radio programmes.Churches were also identified as sources of sex-relatedinformation for young people. However, research partici-pants argued that churches only reached those that werepreparing for marriage and that very few adolescents orga-nized their sexual relationships and marriages throughchurch anymore. Apart from preparation for marriage,churches were noted to lack adolescent-specific sex educa-tion programmes because the church never perceived ado-lescents as sexually active before marriage. This, however,was no longer the case for many displaced young people.While some literature on sex had found its way intothe camps, most discussed sexual performance but notsexual education. Most magazines emphasized sex styles,methods of luring women and men into sex and otherissues related to sexual performance, not anticipation ofand prevention of potential risks. Further, althoughStraight Talk articles found in newspapers available inthe camps contained useful sexual information, access tothis information required purchasing the newspaper, animpractical and expensive luxury for most adolescents.Moreover, the articles were written in English making itdifficult especially for those adolescents who were out ofschool to benefit from their content.Although many participants (68% of individual inter-views) reported access to information on HIV/AIDS, veryfew (6% of individual interviews) noted sufficient access toinformation on puberty, sexuality, condoms, abortion andpregnancy. Additionally, the majority of participants (73%of individual interviews) articulated an urgent need forsexual health information and services that were adaptiveto the current needs of adolescent girls and could supportgirls in translating their knowledge and awareness of HIV/AIDS into prevention behaviour. As one woman explains:“Other sex related information in this area is urgentlyneeded so that our youths are helped to bring changesin their lives. . .but without that then at 12 years,13 years you find all girls pregnant.” [(G) AdultWomen]Patel et al. BMC International Health and Human Rights 2012, 12:38 Page 8 of 12http://www.biomedcentral.com/1472-698X/12/38DiscussionIt is well known that displaced people, particularly girlsand women, are at a much higher risk than the rest of thepopulation for communicable diseases and other healthconcerns including HIV/AIDS [27]. However, the combi-nation of economic, social, biological, and behavioural fac-tors that increase adolescent girls’ sexual vulnerability intimes of war and render them disproportionately suscep-tible to HIV/AIDS is not yet perfectly understood.In study interviews many women commented that,“we have lost control of our children” and “we are ex-periencing complete familial and cultural breakdown”.This research process has furthered our understandingof parental and extended family frustration and anguishregarding the vulnerability of their daughters living insqualor, impoverished and hungry. The lack of controlthey feel they have over the well being of the girl-childstands in stark contrast to the systems of protection inexistence prior to IDP camp relocation. In many wayswomen – grandmothers, aunties and mothers – werethe active witnesses/player/consenters in the transitionof their daughters from adolescence to womanhood.However, the personal security and support offered togirls by their families was virtually extinguished uponthe advent of war. Traditional mentoring systems andcultural norms that previously governed girls’ sexual be-haviour and provided cultural cohesion and guidance insupporting and protecting young girls from risky beha-viours, have largely been eroded by war-induced dis-placement. In IDP camps the mentoring systems arelimited by the close proximity between families, thusrestricting the traditional comfort that had been asso-ciated with the grandmother’s hut. Further, culturalnorms governing girls’ sexual behaviour have disinte-grated because the family unit is now broken-up anddispersed among other families. These findings demon-strate that children no longer have a culturally ‘safe’place to go for information on sexual matters.Research suggests that the erosion of belief systemsand a shift in cultural norms governing girls’ sexual beha-viour in times of conflict helps to explain their heightenedsexual vulnerability during war [28]. This breakdownincreases the likelihood of early sexual debut, unprotectedsexual activity and larger numbers of sexual partners[17,29]. It is clear that the erosion of family and other so-cial and cultural processes needs to be meaningfullyaddressed through appropriate programming if the vulner-ability of girls in conflict settings is to be mitigated. TheGovernment of Uganda is reinstating plans for ‘resettle-ment’ in the northern region as relative peace prevails [30].Post-conflict prevention planners must recognize that therealities of girls will not necessarily change when peaceensues. Although the long-term effects of conflict on chil-dren is rarely discussed, available evidence suggests thatgirls’ vulnerability to sexual and intimate partner violencedoes not necessarily end with the cessation of armedconflict; in fact in many instances their vulnerability is exa-cerbated by reconstruction programmes that fail to speci-fically target their needs [16,17]. Therefore, any planningfor resettlement must incorporate the adequate provisionof basic humanitarian services, including HIV preventionprogramming, particularly for children already traumatizedby war. Moreover, as people are leaving camps and movingback to their home villages there is more room to buildmultiple huts for one family. Hence, families should beencouraged and supported in building several huts for theirhomestead and resettling according to clan and/or in closeproximity to members of extended families (i.e. clusterhomes), as the Acholi once resided before the war. Livingwith and/or near family members will help reinstatetraditional child protection components of the Acholicompound, family and moral value systems while also pro-viding increased security for adolescent girls. Indeed, re-search suggests that in places where values and principlesmirrored by familial and clan obligation remain strong des-pite the war, kinship-related interventions may provide theonly opportunity for consistent programming in conflictsettings [31].Devoid of any means of livelihood in the camps, apeople of agriculturalists and livestock breeders have beenreduced to near total dependence on donated food andother humanitarian aid. The anguish of poverty and theextreme difficulties women and girls face to provide fortheir families in IDP camps is demonstrated in our results.With no land to cultivate or crops to harvest the oppor-tunities are restricted for girls who are out of school tomake money to procure items that they consider import-ant (including soap, Vaseline, panties and dresses). Theseresults are worrisome because of the potential for girlsparticipating in transactional or survival sex relationshipsand early marriages, which inherently increase adolescentgirls’ sexual vulnerability [32]. Mothers in this studyindicted selling portions of WFP food rations to buy thethings they felt their daughters needed to prevent the ini-tiation of sex for exchange relationships. It is clear that inorder to alleviate the vulnerabilities of adolescent girls intimes of conflict, women and girls must be supported inproviding for their families. The provision of marketableskills training in camp settings is therefore very important.However, appropriate skills training relevant to the marketeconomy and camp living must be considered. For ex-ample, training in tailoring might not be relevant becausethere is no one to buy new clothing; however, with amicro-credit loan girls might be able to buy a bail of usedclothing and sell it in a market. By decreasing the depend-ence of girls on men for economic security, adolescentgirls’ sexual vulnerability will intrinsically be alleviated[17,32]. Therefore, local and international NGOs must bePatel et al. BMC International Health and Human Rights 2012, 12:38 Page 9 of 12http://www.biomedcentral.com/1472-698X/12/38encouraged to initiate and support appropriate marketableskills training (e.g., hairdressing and catering courses) tofemale camp residents, particularly adolescent girls whoare not in school.According to the Uganda AIDS Commission and rein-forced by our study results, Ugandan youth begin sexualactivity at young ages and with little information onsexuality thereby increasing their risk of contractingHIV/AIDS [33]. Traditionally, premenstrual sex was for-bidden in Acholi culture and age of sexual debut rangedfrom 16–18 years. The diminishing age of sexual debutfor girls observed in this study, reported by manywomen to be between 12–14 years old, is telling of ado-lescent girls’ increased sexual vulnerability in times ofconflict. Often out of economic need girls are having sexearlier and with older men, and some men seek youngergirls as sexual partners in the belief that they are morelikely to be HIV-negative. Age disparities in sexual rela-tionships increase the likelihood of sexual coercion andinhibit girls’ ability to control the terms of their sex livesincluding negotiating condom use, subsequently increas-ing their exposure to HIV [34].Furthermore, literature suggests that early sex may in-crease the likelihood of early marriage and pregnancy,signalling the end of education for most girls and leavingadolescent girls even more at risk of poverty and sexualexploitation [35]. Our study results corroborated this li-terature, as the primary reasons reported by girls fordropping out of school were marriage and/or pregnancy,in addition to lack of money for school-related supplies(uniforms, books, meals). Moreover, our results demon-strated that girls who were not in school were being leftbehind in the camps for most of the day instead of ac-companying and assisting their mothers in the gardens,due to fear of abduction. These circumstances left out-of-school girls unsupervised in camps during the dayincreasing the potential for sexual predation by menoffering food and clothing in exchange for sex. A reportby UNICEF found that after families, schools are thenext perimeter of a protective environment for children[36]. Schools can be a powerful protective force in mostchildren’s lives, especially for girls, as schools physicallyremove children from potential harm for much of theday and help children learn skills and gather informationto protect themselves and delay on-set of sexual activity.The longer girls are kept in school their vulnerability toHIV infection lowers by approximately thirty per cent[36]. Consequently, in-light of the widespread benefits ofeducation, including the physical protection and sexualsecurity that schools can provide to adolescents, everyeffort must be made to ensure displaced girls have con-sistent and stable access and support in their academicsin times of conflict. Therefore, educational responsesfrom the Ugandan Government and NGOs in northernUganda must prioritize the provision of policies and pro-grammes that support adolescent girls in attending andmaintaining their in-school status, particularly youngmothers with children and girls who are married. Cur-rently, due to restrictive national policy, girls who getmarried or become pregnant are generally forced out ofschool. After substantial time away, the majority of thesegirls do not end up re-entering the school system, mainlydue to the stigma associated with older girls re-enteringschool with their younger peers and, lack of childcaresupport for young mothers [37]. As such, it is imperativethat the Ministry of Education in Uganda restructurecurrent educational policy so that young girls who becomepregnant or get married are not forced to leave school.Moreover, this policy change must coincide with the de-velopment of special bridging centres (attached to govern-ment schools) for young mothers where they can continuewith their formal education while their children are caredfor. In addition, the Ministry must ensure that older girlswho drop out of school are afforded the opportunity ofaccessing accelerated learning programmes, complemen-tary educational initiatives which allow young people tocatch-up with their studies relative to their peers, in-turnincreasing the chances of school leavers re-entering theformal education system. Finally, the Government ofUganda and the Ugandan Ministry of Education mustwork with the districts and sub-districts in the North, aswell as local NGOs and international donor agencies, toprovide funding for all the ‘extras’ that keep children fromentering/re-entering school or force school-going childrento subsequently drop-out (i.e. uniforms, books, meals).Our study results demonstrated that girls were also vul-nerable at night; our analysis uncovered a very concerning‘internal’ night-commuting phenomenon whereby, due toprivacy and security concerns, children moved from theirfamily hut at night from the outskirts of camps to sleep inmore central locations within their camp’s perimeters in afriend’s or relative’s hut without any adult supervision.Many parents reported the increased vulnerability of theirdaughters, in particular, to sexual predation during thisinternal nighttime movement. Unfortunately, the hun-dreds of children moving at night within the perimeters ofthe camps has not been highly recognized as a night-commuting phenomenon in and of itself, and has there-fore not been properly assessed from either a research ora policy perspective. A concerted effort by researchers,policy makers and, programme planners to address theseunique circumstances is urgently required.In Northern Uganda, the Information, Education, andCommunication (IEC) campaigns focused on the dis-semination of HIV/AIDS information can be consideredsuccessful, as the majority of our study participants hada high awareness of HIV/AIDS and a high knowledgelevel of how to prevent infection. Yet what is apparentPatel et al. BMC International Health and Human Rights 2012, 12:38 Page 10 of 12http://www.biomedcentral.com/1472-698X/12/38in our analysis is that girls are having difficulty transla-ting knowledge of how to prevent infection into riskminimization practice. Many girls reported that condomavailability in the camps was inconsistent or unavailablealtogether. Moreover, several participants expressed theneed for sexual health information and services in campsthat was cognizant of the current realities and needs ofadolescent girls and that would support them in thetranslation of HIV/AIDS awareness and knowledge topersonal modification of sexual lifestyles. Combined,these findings are an indicator of the lack of appropriatesexual health programming that exists in camps and areof concern. With limited access to knowledge and meansto protect one’s self, girls are inherently vulnerable tohigh-risk sexual activity [38]. It is well documented thatwar-related insecurity has diminished opportunities forNGOs and other organizations providing preventionprogramming to have a strong and consistent presencein displacement camps [17,39,40]. However, researchdemonstrates that reduced access to reproductive andsexual health services including relevant sexual healthinformation increases the vulnerability of adolescents inparticular [29]. Prevention programming planners incamps must realize that early sex, early marriage, andearly pregnancies are the realities of adolescent girls li-ving in displacement camps. Appropriate responses andinnovative community-driven solutions acknowledgingthis actuality are urgently required to ensure adolescentgirls have support and access to the information andmeans they need to protect themselves. For example,Spittal et al. (2008) developed the Wayo Programme, areproductive health initiative in northern Uganda thattrained women from the community to assume tra-ditional Acholi, wayo-like counselling roles for the pur-poses of passing on sexual education and HIV preventioninformation from adults to younger women [31]. This is ahighly successful and sustainable initiative because thewomen themselves are chosen by the community to be-come trained in STI prevention, condom use and repro-ductive health issues. They essentially resurrect roles thatcarried traditional respect; roles, which have now been lostor eroded due to prolonged conflict and displacement.Similar interventions that are built solidly upon indigen-ous knowledge and supported by the community must besupported and expanded. Furthermore, consultationsmust occur between the Wayo Programme, girls at risk,and other NGO and service providers in northernUganda, including Save the Children, The AIDS SupportOrganization (TASO) and Straight Talk, on ways to in-crease access to condoms, condom information, VCT, STItreatment and antiviral care in camp settings. Strengthen-ing reproductive health service provision to adolescentgirls in times of conflict would improve their health out-comes considerably [17].ConclusionsDeparting from the recognition of a paucity of know-ledge on the distinct vulnerabilities of adolescent girls intimes of conflict, this study sought to explore the sexualvulnerabilities of displaced adolescent girls in NorthernUganda. Our analysis identified the erosion of tra-ditional Acholi mentoring and belief systems that hadpreviously served to protect the girl child’s sexuality, inaddition to a collapse of livelihood in the face of war.These factors coupled with: being left in camps un-supervised and not in school during the day; movementwithin the perimeters of the camp at night away fromthe family hut to sleep in huts closer to the center of thecamp due to fear of abduction and cultural considera-tions pertaining to privacy, and; inadequate access torelevant and adaptive sexual health information andprogramming in the IDP camps, have all contributed toadolescent girls’ heightened sexual vulnerability andsubsequent enhanced risk for acquiring HIV/AIDS inconflict settings. It is safe to say that the lives of Acholigirls and women have been irrevocably impacted byover two decades of war and displacement. Conflict pre-vention planners, resettlement programme developersand policy-makers must recognize adolescent girlsaffected by armed conflict as having distinctive needs,which may not be the same as women, children or ado-lescent boys. Moreover, the unique needs of conflict-affected adolescent girls require distinctive responses.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsPMS and NKS developed the study design with assistance from HM, GO andSA; SA collected the data with oversight from NKS, HM and GO; SHPpreformed the data analysis and drafted the manuscript; SHP, PMS, NKS, HMand SA were responsible for the interpretation of results and final revisionsto the manuscript. All authors read and approved the final manuscript.AcknowledgementsWe are deeply grateful to all the study participants for sharing their stories,hopes and fears. We would also like to acknowledge our Acholi researchteam in Uganda for their dedication, support and invaluable insights.FundingSupport for this study was provided by the Canadian InternationalDevelopment Agency (CIDA), through the Child Protection Research Fund.CIDA had no further role in study design; in the collection, analysis andinterpretation of data; in the writing of the report, or; in the decision tosubmit the paper for publication.Author details1Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada.2School of Population and Public Health, University of British Columbia,Vancouver, BC, Canada. 3Child Health and Development Centre, MakerereUniversity, Kampala, Uganda. 4Makerere University College of HealthSciences, Kampala, Uganda. 5Child Protection Programme, Save the ChildrenLiberia, Monrovia, Liberia. 6Community-based Researcher, Gulu Town,Uganda.Received: 28 January 2012 Accepted: 4 December 2012Published: 28 December 2012Patel et al. 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Geneva,Switzerland: UNHCR; 2006.doi:10.1186/1472-698X-12-38Cite this article as: Patel et al.: In the face of war: examining sexualvulnerabilities of Acholi adolescent girls living in displacement camps inconflict-affected Northern Uganda. BMC International Health and HumanRights 2012 12:38.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitPatel et al. BMC International Health and Human Rights 2012, 12:38 Page 12 of 12http://www.biomedcentral.com/1472-698X/12/38


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